Celiac Dx

Question 1

How to treat Celiac dx

Answer 1

dietary counseling with dietician,
monitor lifelong adherence to gluten free diet

access to an advocacy group

Question 2

what are celiac pts at risk for?

Answer 2

mineral deficiencies, and osteopenia and osteporosis

and peuropsychiatric illness( peirpheral neuropathy, headache, depression) and skin disorders

Question 3

What kind of nutritional deficiencies can pts with celiac dx suffer from?

Answer 3

iron, calcium, vitamin D, folic acid and rarely thiamine

Question 4

when to screen for osteopenia and osteoporosis in a celiac pt?

Answer 4

obtain DEXA at diagnosis
repeat DEXA 1 year later if osteopenia is present

have increased bone loss due to vitamin D deficiency

Question 5

What vaccination to give celiac pt?

Answer 5

pneumococcal vaccination because Celiac pts tend to have hyposplenism

Question 6

How to treat dermatitis herpetiformis?

Answer 6

dapsone in addition to gluten free diet

Question 7

Presentation of celiac pt

Answer 7

young person with weight loss and diarrhea and may have skin rash that looks like herpes

Question 8

complications of celiac disease

Answer 8

malabsorption of vitamin D, iron deficiency anemia and low urinary calcium excretion.

Can also cause osteoporosis.

Question 9

relatively common cause of Fe deficiency anemia

Answer 9

Celiac’s dx

Question 10

what causes persistent bowel syndromes in celiac sprue?

Answer 10

poor dietary compliance/symptom recurrence
refractory sprue
EATL (enteropathy associated T cell lymphoma) and ulcerative jejunoileitis
other coexisting conditions like: lactose intolernace, IBS, pancreatic insufficiency, microscopic colitis and small bowel bacterial bowel overgrowth

Question 11

what are clinical clues that a pt with celiac sprue may have poor dietary compliance/symptom recurrence?

Answer 11

inadvertent gluten ingestion most common cause

persistent histological abnormalities, high antibody titers and careful dietary history and diagnosis

Question 12

what are clinical clues that a pt with celiac sprue may have refractory sprue?

Answer 12

Type 1: no initial response to gluten free diet for 12 months

Type 2: initial response to gluten free diet but symptoms return despite dietary adherence

poor prognosis and frequent progression to EATL (enteropathy associated T cell lymphoma) and treatment involves glucocorticoids

Question 13

what are clinical clues that a pt with celiac sprue may have EATL (enteropathy associated T cell lymphoma) and ulcerative jejunoileitis?

Answer 13

due to aberrant T cell populations
presents with abdominal pain and B symptoms and GI bleeding
often presents with intestinal obstruction and perforation
no response to steroids

Question 14

3 months of fevers, abdominal pain and melena and diarrhea in a celiac pt who affirms that they are eating a gluten free diet

Answer 14

concerning for intestinal lymphoma or enteropathy associated T cell lymphoma
seen pts who have poor dietary compliance

rare and aggresive lymphoma

Question 15

Clinical symptoms of enteropathy associated T cell lymphoma

Answer 15

abdominal pain, hepatosplenomegaly, ascites, duodenal masses B symptoms (night sweats, fevers, weight loss) and GI bleeding.

May present with obstruction or perforation

Question 16

Where is the tumor located in enteropathy associated T cell lymphoma

Answer 16

proximal jejunum and less frequently in stomach, small bowel or colon.

Question 17

what helps to reduce the incidence of enteropathy associated T cell lymphoma

Answer 17

gluten free diet

Question 18

enteropathy associated T cell lymphoma is rarely seen in

Answer 18

<33 yrs.

Question 19

diagnosis of enteropathy associated T cell lymphoma

Answer 19

biopsy of resected tumor

see multiple jejunal ulcers with gut perforation

Has poor prognosis and treatment is combination of other therapy with other aggressive T cell lymphomas.

Question 20

uncontrolled celiac dx causes:

Answer 20

decreased GI vitamin D absorption and see subsequent vitamin D deficiency

This causes hypocalcemia and secondary hyperparathyroidism that elevates PTH

PTH compensates by decreasing urinary Ca nad increases urinary phosphate excretion and normalizes serum Ca but lower serum phosphate.

Question 21

what happens with prolonged vitamin D deficiency?

Answer 21

see osteomalacia, and inaccessible calcium stores in bone (unmineralized osteoid) and eventual hypocalcemia.

They can develop pseudofractures, bone pain and deformity

Question 22

extraintestinal manifestations of celiac dx: general

Answer 22

fatigue and weight loss

Question 23

extraintestinal manifestations of celiac dx: skin

Answer 23

vitiligo

dermatitis herpetiformis

Question 24

extraintestinal manifestations of celiac dx: MSK

Answer 24

osteopenia/osteoporosis
osteomalacia

due to low vitamin D absorption and see elevated PTH levels

Can see elevated alkaline phosphatase levels and hypocalcemia and hypophosphatemia (From PTH)

Question 25

extraintestinal manifestations of celiac dx: hematological

Answer 25

anemia

Question 26

extraintestinal manifestations of celiac dx: neurological

Answer 26

headache

peripheral neuropathy

Question 27

extraintestinal manifestations of celiac dx: endocrine

Answer 27

autoimmune thyroiditis (hyper or hypo)
DM1

Question 28

extraintestinal manifestations of celiac dx: psychiatric

Answer 28

depression

psychosis

Question 29

when to get DEXA scan for someone with celiac dx?

Answer 29

at time of diagnosis

regardless of age or menopause status

Question 30

how to treat pts who have celiacs dx and possible osteopenia or bone disease?

Answer 30

Need calcium and vitamin D supplementation
need to get DEXA scan at time of diagnosis regardless of age or if post menopausal

gluten free diet does improve bone density slightly

Question 31

serum IgA tissue transglutaminase antibody (or deamidated gliadin antibody) levels can be used to asses response?

Answer 31

yes. Can see it go to low titers after 3-12 months of gluten free diet.

Some people say to do a repeat EGD to assess response but this is done after 4-6 months of dietary modification

Question 32

celiac can present with only:

Answer 32

elevated aminotransferases

infertility

arthritis and neurological symptoms
and osteoporosis

Question 33

iron deficiency anemia and arthritis and infertility and elevated aminotransferases

Answer 33

screen for celiac dx.

Question 34

pt has signs and symptoms of celiac dx (diarrhea, weight loss) no rash. EGD with biopsy shows villous atrophy and increased intraepithelial lymphocytes in 1st part of duodenum. total IgA and tissue transglutaminase serological testing all show no celiac dx.

what is it?

Answer 34

check medication list.

Olmesartan can mimic refractory celiac dx.

olmesartan medoxomil can cause a sprue like enteropathy and this can develop months to years after starting olmesartan.

can mimic refractory celiac sprue with villous atrophy and increased intraepithelial lymphocytes in first part of duodenum.

see severe weight loss and diarrhea and dehydration needing hospitalization.

Question 35

drug induced sprue like enteropathy tx

Answer 35

treat by stopping the medication

the symptoms and pathological changes will stop after medications are stopped.

Question 36

initial screening test for celiac’s

Answer 36

IgA anti tissue transglutaminase

confirmation testing is with IgA antiendomysial antibodies.

if both positive then needs EGD for biopsy of duodenum to confirm villous atrophy to make diagnosis.

Question 37

what vaccine do you give everyone with celiac’s dx?

Answer 37

pneumoccocal vaccine. they have hyposplenism reported and relatively common.